Housing and health Working together to respond to rough sleeping during Covid-19 - January 2021 - St Mungo's
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January 2021 Housing and health Working together to respond to rough sleeping during Covid-19
Acknowledgements We would like to thank everyone who contributed to this report, especially the St Mungo’s hotel managers whose insights were invaluable. We are also grateful to the St Mungo’s clients who participated in the forums to help shape this report. Additionally, we would like to thank the health and homelessness professionals, policy makers and researchers who shared their expertise. Foreword from Nathaniel (St Mungo’s client and member of Outside In) During these unfortunate times of a global pandemic, homelessness and rough sleeping should be at the forefront of national debate – but more so, action should be taken. This has been a really tragic situation. But there has been one blessing in progress of government measures allowing some homeless people new accommodation like hotels. When I was homeless, systematic engagement while I was in Recovery House was vital at a time when I was vulnerable. I was able to build a rapport and trust and establish lines of communication to build bridges to alleviate my homelessness. Having this positive experience during that point in my life helped me establish a pathway to helping others out of homelessness and working in care and support. It turned my negative experiences into driving me to positive work and change. This was all because I was somewhere with active engagement and my health and wellbeing was being looked after. If others could also get support like I did, countless people could benefit from help with being homeless but also having long term health care and rebuilding their lives. Having healthcare interlinked from the initial contact point helped me hugely and should be provided for others. Short term and long term plans must be put in place to allow homeless people to flourish in society as well as be safe during the pandemic. We can make a better future, by understanding the present and learning from the past. 2
Contents
Section 1 Executive Summary 4
Section 2 Methodology 10
Section 3 Policy Context 12
Section 4 The health needs of homeless people 16
Section 5 Assessing the health needs of homeless people during Covid-19 20
Section 6 Addressing the health needs of homeless people during the Covid-19 crisis 24
6.1 Health outcomes for people who were brought in to hotel accommodation 25
6.2 Challenges for those in existing homelessness services 29
Section 7 What has led to this improvement in health outcomes for those in
emergency hotel accommodation? 30
7.1 The response put saving lives first and foremost 31
7.2 There was a huge collaborative effort at national and local level 32
7.3 Eligibility rules were more flexible, allowing more people to
move into accommodation 34
7.4 There was increased support available 34
7.5 Safe, clean and reliable accommodation was provided 36
7.6 Push factors encouraged people sleeping rough to engage with the support on offer 37
7.7 The impact of Covid-19 on healthcare services forced new ways
of working with mixed results 38
Section 8 Conclusion and recommendations 42
3
Section 1 Executive Summary 1 Executive Summary 4
Covid-19 has exposed, and in some cases exacerbated,
existing health inequalities in the UK.1 People who are
“It’s taken the coronavirus crisis
homeless have worse health than most, and yet they find
it harder to get the healthcare they need.2 During the
for people to see rough sleeping
pandemic, the Government rightly recognised the significant for the public health emergency
threat to health posed by sleeping on the street and in
communal shelters. Through focusing on getting ‘everyone it is.” 4
in’ and providing safe accommodation, many lives were saved. Baroness Louise Casey
Furthermore, it connected people sleeping rough to the care,
support and treatment they desperately need.
Everyone In has redefined what can be achieved when there is
In their 2019 manifesto, the Government pledged to end rough
a singular shared goal of saving lives. International comparators
sleeping by 2024 and to “bring together local services to meet the
highlight the success of this approach. Analysis in August 2020
health and housing needs of people sleeping on the streets.”3 During
found there were at least 25 times fewer laboratory confirmed
the coronavirus pandemic, both the health and housing needs
cases of Covid-19 amongst the homeless population in London
of many of those sleeping on the streets have been addressed
than in New York.5
in tandem. The Everyone In initiative – which, according to
Government estimates, has led to more than 33,000 people This report presents the findings of new research into the health
being moved into safe, emergency accommodation in England - needs of people sleeping rough in England and their vulnerability
was a monumental, collaborative effort involving both health and to Covid-19, and the approach taken to address the health and
homelessness services, as well as national and local government, housing needs of this group during the pandemic. The report is
corporate partners and community volunteers. also informed by our detailed knowledge as a service provider
and by the lived experience of our clients. The aim is to help
inform decision makers in government, local authorities and the
health service and offer solutions to rough sleeping, both during
the ongoing pandemic and beyond.
1 Public Health England (2020) COVID-19: review of disparities in risks and outcomes
https://www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes
2 St Mungo’s (2014) Homeless Health Matters: the case for change https://www.mungos.org/publication/homeless-health-matters-case-change/
3 Conservative Party (2019) The Conservative and Unionist Party Manifesto 2019
https://assets-global.website-files.com/5da42e2cae7ebd3f8bde353c/5dda924905da587992a064ba_Conservative%202019%20Manifesto.pdf
4 Casey L., Mohan N. (2020) It’s taken the coronavirus crisis for people to see rough sleeping for the public health emergency it is
https://www.kcl.ac.uk/news/its-taken-the-coronavirus-crisis-for-people-to-see-rough-sleeping-for-the-public-health-emergency-it-is
5 Hayward, A., Story, A. (2020) Public Health rationale for not opening/re-opening communal airspace sleeping facilities for homeless people during the SARS-CoV-2 pandemic
https://www.pathway.org.uk/wp-content/uploads/UCL-CCIH-Faculty-Position-Statement-Aug-2020-Communal-Airpsace-Sleeping-Facilities-AS-AH.pdf
5
Section 1
Key findings
People who sleep rough frequently have extremely poor 1 in 4 of St Mungo’s clients have
health and are very vulnerable to severe cases of Covid-19. an underlying health condition
▪ A Covid-19 health assessment carried out across St Mungo’s which puts them at risk of more
services – covering 4,924 clients, 939 of whom were in the severe cases of Covid-19
emergency hotels -- found that between July and December
2020 a quarter (24%, 1,005 people)6 had an underlying health
condition which put them more at risk of suffering from acute
Almost a fifth of St Mungo’s clients
cases of Covid-19, for instance severe respiratory conditions in emergency hotels were not
such as chronic obstructive pulmonary disease (COPD). registered with a GP when they
moved in
▪ 18% (132 people) of St Mungo’s clients supported in
emergency Covid-19 hotels were not registered with a GP
when they moved in. In comparison, 98% (1,907 people) of
clients across St Mungo’s supported housing and Housing First,
28% of St Mungo’s clients in
were registered with a GP. emergency hotels were classed as
vulnerable or extremely vulnerable
▪ A Covid-19 health assessment, carried out by the University
to Covid-19
College London Hospital (UCLH) Find & Treat team, found
that 6% of people accommodated in emergency hotels in
London between July and October had extreme clinical
vulnerability in relation to Covid-19 — nearly double that of
the general population. 33% had moderate clinical vulnerability.
Housing First
Again, this is more than double that found in other cohorts of Emergency
and supporting
the population, for example, ONS data showing 15% of key hotel clients
housing clients
workers have moderate clinical vulnerability.7
Vulnerable or
St Mungo’s clients living in supported housing and Housing 28% 54%
extremely vulnerable
First services have even higher health support needs than
those in emergency hotels, which is to be expected given the Required regular
tailored support provided by such services for people with 37% 74%
prescription
the highest needs.
▪ 28% (203 people) of clients in emergency hotels were classed Mental health
37% 82%
as vulnerable or extremely vulnerable to Covid-19. This rose support needs
to 54% (85 people) of clients in St Mungo’s Housing First
Physical health
services. 36% 58%
support needs
▪ Just over a third (37%, 270 people) of clients in emergency
hotels required a regular prescription compared to 74% Drug support needs 31% 55%
(1412 people) of clients in Housing First and supported
housing services. Alcohol support needs 36% 38%
▪ 37% (243 people) of clients in emergency hotels had mental Underlying
health support needs compared to 82% (1588 people) of health condition 19% 30%
clients in Housing First and supported housing services. (Covid-19 specific)
6 The percentages are based on the total number of people excluding unknowns.
7 ONS (2020) Coronavirus and key workers in the UK
https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/earningsandworkinghours/articles/coronavirusandkeyworkersintheuk/2020-05-15
6
Executive Summary
People who have started sleeping rough, or who have Through semi-structured interviews with individuals from
remained on the streets during the pandemic also have high health and homelessness services, government departments
levels of comorbidity and complex needs. and agencies, and people who had experienced rough
▪ Data from the July-September Combined Homelessness and sleeping, we identified the key factors driving improved health
Information Network (CHAIN) report of rough sleeping in outcomes for people who had been rough sleeping and were
London showed 44% (1011 people) seen sleeping rough housed in hotels. These were:
during July to September 2020 had mental health support ▪ Safe, secure and clean accommodation, with meals provided.
needs. 33% (761 people) had drug support needs.8 The use of self-contained accommodation reduced the risk
of transmission of Covid-19 and helped ensure people could
▪ A third (33%, 744 people) of people seen sleeping rough in
self-isolate if needed.
the capital during the same period had at least two identified
support needs in addition to their homelessness. These related ▪ Having support workers on site to help people follow public
to mental health, alcohol or drug problems, with 9% having all health guidance, manage any issues with their accommodation
three additional support needs (210 people).9 and cope with complex problems related to their
homelessness, such as drug and alcohol and mental health
The response to rough sleeping during the pandemic has problems.
saved lives, as well as producing other positive outcomes for
many of those housed in hotels. ▪ The close involvement of health services to provide
support and healthcare in the emergency accommodation
▪ Research published in The Lancet Respiratory Medicine
where people were staying.12 This support has been
journal found that 266 deaths were avoided in the homeless
provided regularly and consistently, and from a position of
population in England during the first wave of Covid-19, owing
understanding the full extent of an individual’s support needs,
to the action taken. Furthermore, 1,164 hospital admissions
rather than trying to treat related problems separately.
and 338 ICU admissions were also avoided.10
▪ The triage, assess and cohort model which ensured people
▪ The UCLH Covid-19 health assessment found that more
were grouped on the basis of their clinical vulnerabilities and
than a third (35%) of those assessed in the emergency hotel
medical needs, including separate accommodation for people
accommodation in London said their physical health had
with Covid-19 symptoms. This reduced the risk of infection
improved since moving into a hotel.
and allowed focused medical support to be provided – the
▪ Significant numbers of people who had not previously benefits of which extended beyond maintaining people’s
accessed treatment have been supported by drug and alcohol immediate welfare during the pandemic. Stretched health
services during the pandemic. Between April and September, services could be targeted at concentrated populations of
the Homeless Hotel Drug & Alcohol Support Service (HDAS) people who needed them the most.
in London supported 75 new people who had never accessed
treatment services before.11 Notwithstanding the many positives for those previously
sleeping rough who came into hotel accommodation, for
others, this period has seen significant challenges. For those
who remained, started or returned to rough sleeping during
the pandemic, the closure of normal services such as day
centres and communal night shelters, as well as the reduction
in drop-in health clinics, has been hugely difficult. Some St
Mungo’s clients also reported feeling isolated and lonely
during the lockdown, and that the anxiety and stress from
this period, and their lack of social interaction, exacerbated
existing mental ill health.
8 GLA (2020) CHAIN Quarterly Report Greater London July - September 2020 https://data.london.gov.uk/dataset/chain-reports
9 Ibid
10 Lewer, D., et al. (2020) COVID-19 among people experiencing homelessness in England: a modelling study
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30396-9/fulltext
11 Pan-London Homeless Hotel Drug & Alcohol Support Service (HDAS) (2020) Lessons Learned http://osf.io/7cdbx/
12 In May 2020, 17 out of 23 emergency hotels being managed by St Mungo’s had support from local health services.
7
Section 1
Recommendations 4 Ensure that people who are homeless are prioritised for
the Covid-19 vaccine – It is extremely positive that frontline
There are still many people sleeping rough and more are
workers who support people experiencing homelessness are
at risk of joining them as the recession bites. In light of the
among the first groups able to receive a Covid-19 vaccine,
health needs and increased vulnerability to Covid-19 of those
along with other health and social care workers. It is also
sleeping rough, we must ensure that the lessons from the last
crucial that those who are homeless are prioritised. As a
few months are used to inform future plans to achieve our
result of the significant barriers to healthcare faced by people
collective aim of ending rough sleeping.
who are homeless, many will not have been identified as
clinically vulnerable and therefore requiring priority access
Immediate action needed while the to the Covid-19 vaccine. As part of the vaccine roll-out, the
Covid-19 pandemic continues Government should ensure there is a comprehensive plan to
identify and deliver the vaccine to people who are homeless.
1 Encourage stronger partnerships between housing and
As part of this, the Government has rightly identified the
health services – The Ministry of Housing Communities and
need for a GP registration drive, but the plan must also
Local Government (MHCLG), the Department of Health
include proactive and sustained outreach by health services
and Social Care (DHSC), Public Health England (PHE) and
working in partnership with local authorities, homelessness
NHS England and NHS Improvement (NHSE/I) should
services and people with lived experience of homelessness.
maintain the close working arrangements developed during
There is also a strong case for ensuring all homeless people
the Covid-19 pandemic to support local authorities and
are prioritised for the vaccine given their vulnerability to
local health services to continue with the assessment, triage,
severe cases of Covid-19.
cohort and care approach that saved lives in the first wave
Covid-19.
Beyond the pandemic
2 Secure the successes of the principles of Everyone In by
Our recommendations to national government
ensuring that sufficient, safe accommodation is in place for
everyone that needs it – The discovery of the new, highly 5 Strengthen joint work on homelessness across
transmissible variant of Covid-19, in addition to the cold government – A new inter-ministerial working group or
winter weather, means there is an urgent need to protect cabinet committee on homelessness and rough sleeping
the health of everyone sleeping rough. Moving forward the should be established. Ministers across government need
Government should provide additional funding and support to be able to offer solutions, and be held accountable for
to local authorities to ensure they are able to offer sufficient, the Government’s goal to end rough sleeping by 2024.
self-contained emergency accommodation for everyone who Furthermore, the Government should always consider
is sleeping rough, or at risk of doing so while the pandemic homelessness and rough sleeping when responding to
continues. This includes accommodation with high levels national emergencies, particularly where there is an
of support and medical input for those with multiple and immediate risk to health.
complex needs, or for those who are clinically vulnerable 6 Extend the coverage of specialist homeless health services
who need to shield. This approach should be a core aspect – There should be more multi-disciplinary teams providing
of any future emergency response that impacts upon those integrated mental health and substance use services that are
who are homeless or at risk of sleeping rough. joined up with housing and homelessness services in order
3 Ensure continued access to emergency accommodation, to reach people with multiple and complex needs. Existing
immigration advice and employment support for people programmes must continue and funding must be provided
with No Recourse to Public Funds (NRPF) who are to ensure services can reach people in every part of the
sleeping rough – A key principle of the Everyone In initiative country, not just some areas.
was that homeless people were able to access support and 7 Restore £1 billion per year of lost funding for
accommodation regardless of their immigration status. This homelessness and housing related support services –
was particularly important for people who do not usually MHCLG and HM Treasury should restore the funding for
have access to homelessness assistance, or welfare support, homelessness and housing related support services13 that
due to NRPF conditions. The Government should build has been cut from local authority budgets over the past
on the progress made during the pandemic to help end decade via a specific grant to local authorities in the next
rough sleeping for everyone, including non-UK nationals. In Comprehensive Spending Review.
particular, the Government should ensure continued access
to emergency accommodation, and increase investment
in specialist immigration advice and employment support
services that support people to find a route out of
homelessness.
8
Executive Summary
8 Expand the Rough Sleeping Accommodation Programme 12 Local authorities should ensure their homelessness and
(RSAP) – 6,000 homes with support for people who have rough sleeping strategies address health needs. Working
slept rough have been promised by March 2024 and the with the local Health and Wellbeing Board, every local
2020 Spending Review confirmed £87 million capital funding authority should ensure their homelessness and rough
would be made available in 2021-22 to support the delivery sleeping strategy includes an assessment of the health needs
of these homes. However, further investment will be needed of people who are homeless. Local strategies should also
to ensure everyone housed in emergency accommodation include measures to reduce health inequalities experienced
gets the right housing and support they need to leave rough by people who are homeless, and ensure people get the
sleeping behind for good. support they need to improve their health and move on
from homelessness.
Our recommendations to local leaders
13 Health services should take steps to improve digital
9 NHS organisations should work with local authorities and
inclusion. NHSE/I has said that all GP practices must offer
homelessness organisations to develop and implement
face to face appointments at their surgeries as well as
effective delivery plans to ensure that people who are
continuing to use remote consultation.14 However, online
homeless are able to access the Covid-19 vaccine.
consultations remain a principal option for many services
This includes tailored communication, alongside proactive
and more must be done to prevent further exclusion among
in-reach and outreach programmes, such as replicating the
people who struggle to access services remotely, including
mobile vaccine units deployed to care homes for hostels and
people who are homeless.
day centres.
14 Local authorities and Clinical Commissioning Groups
10 NHS organisations should ensure their work to reduce
(CCGs) should increase the number of jointly
health inequalities always considers people who are
commissioned services - Jointly funded and commissioned
homeless. The NHS Chief Executive, Sir Simon Stevens, has
services help ensure support is well integrated and better
asked all parts of the NHS to “take urgent action to increase
able to respond to a range of needs such as homelessness
the scale and pace of progress of reducing health inequalities”.
and poor health. Jointly commissioned services are also
NHS organisations should ensure their plans explicitly cover
important for building strong relationships across different
steps to reduce the health inequalities experienced by people
parts of the local ‘system’ and commissioners are well-
who are homeless and sleeping rough.
placed to help improve service pathways, ensuring they are
11 Sustainability and Transformation Partnerships (STPs) person-centred and not focused on trying to address a single
and Integrated Care Systems (ICSs) should develop clear problem.
plans for delivering integrated housing, mental health and
15 Providers of drug and alcohol services should consider
substance use treatment pathways for people sleeping
a range of options to speed up scripting for opiate
rough. This will help to deliver the goals of the NHS Long
problems. Scripting services should be more flexible to
Term Plan which identifies people sleeping rough as a priority
ensure that people are engaged as early as possible, as we
group, and support the Government’s goal to end rough
have seen with same-day scripting during this period.
sleeping. The plans should be informed by the rapid audit
of health provision targeted at people sleeping rough, which
was carried out in 2018 by DHSC and MHCLG in order to
identify gaps.
13 WPI Economics (2020) Local authority spending on homelessness 2020 update
http://wpieconomics.com/site/wp-content/uploads/2020/02/WPI-Economics-local-authority-homelessness-spending-2020-update-FINAL-images.pdf
14 Pritchard, A., Stevens, S. (2020) Third phase of NHS response to Covid-19
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/07/Phase-3-letter-July-31-2020.pdf
9
2 Methodology 10
This research has been carried out to better understand the Data from St Mungo’s outreach teams on clients’ use of
health needs of people sleeping rough in England and their health services
increased vulnerability to Covid-19, and to learn more about ▪ St Mungo’s outreach services in London use the CHAIN
the approach taken to address the health and housing needs database to record the use of health services by the clients
of this group during the pandemic. This report is intended to they are supporting to move away from rough sleeping. The
inform future service provision from positive practices which ‘events’ recorded show the number of times health services
have emerged. We also hope it will help inform decision were attended rather than the number of unique clients
makers in government, local authorities and the health service accessing a service. For example, one person may have
and offer solutions to rough sleeping, both during the ongoing attended a GP appointment five times and this is recorded
pandemic and beyond. as five ‘events’. The data analysed compares ‘events’ recorded
during the period September 2019-February 2020 and the
For this research, we carried out an analysis of new data sets
period March 2020-August 2020: the six months prior to
including:
lockdown in March and the six months following lockdown in
St Mungo’s Covid-19 assessment March.
▪ This assessment is carried out by St Mungo’s staff with clients St Mungo’s hotel health partnerships survey
from all St Mungo’s housing related support services including,
▪ This was a survey sent to 23 emergency Everyone In hotels
but not limited to, emergency hotels, supported housing and
managed by St Mungo’s in May 2020. This provides a snapshot
Housing First services in the south and south west of England
of the health and social care input to the St Mungo’s hotel
including Brighton, Bristol, Oxford and London. This includes
provision. 17 of the 23 hotels provided a response to the
939 clients in the emergency Everyone In hotels. The data set
survey.
we analysed covered the period from 1 May to 4 December.
In this period it has been completed for 4,922 clients. COVID-19 Homeless Rapid Integrated Screening Protocol
(CHRISP) assessment
▪ This was an in-depth health assessment of clients in hotels
St Mungo’s Covid-19 assessment data
across London led by the University College London Hospital
This was completed for 4,924 clients. This included: (UCLH) Find & Treat team. 1,148 people are included in
▪ 939 clients in the emergency Everyone In hotels the data analysed. The data was gathered between July and
October through a questionnaire completed for clients by
▪ 2051 clients in Housing First and supported housing medically trained staff, all of whom were foundation doctors,
services (these services continued to run with measures GPs or consultants. The majority were carried out via
introduced to keep clients and staff safe) telephone but some were also carried out face to face
▪ 1,343 clients with floating support (tenancy support in hotels.
provided to people in their own housing)
In addition to the data analysis, we carried out semi-structured
▪ 586 clients who engaged with St Mungo’s through interviews with 24 individuals from health and homelessness
other services such as staging post accommodation services and four civil servants working in different Government
(interim accommodation often for people with more departments and agencies. These were all carried out by
complex cases while they wait for a longer-term housing telephone. Quotes from these interviews are included
outcome) throughout the report but have been anonymised.
We also consulted St Mungo’s clients who attended our regular
Policy and Campaign Forum meetings in August and October,
and spoke separately to four clients who had all stayed in
emergency hotels. These meetings were held virtually, with
assistance from our client involvement team and hotel managers.
Finally, we carried out desk-based research of publications
related to rough sleeping, homelessness and health, although this
was not a full literature review.
113 Policy context 12
Before the Covid-19 pandemic, In 2019, the NHS Long Term Plan identified people sleeping
rough as a priority group as part of its commitment to tackle
homeless people were dying on health inequalities. It committed to invest up to £30 million
the streets extra in specialist mental health services, integrated with existing
homelessness outreach services. Funding has so far been
Rough sleeping is the most visible and dangerous form of
provided to seven areas in England and there are plans to fund
homelessness and dying on the streets is its most appalling
services in a total of 20 areas by 2023/24. Crucially, the NHS
consequence. People who sleep rough commonly have
Mental Health Implementation Plan, also published in 2019,
extremely poor health and poor access to health services.
states that “all areas, whether or not they receive funding for new
Poor health and homelessness are closely related problems, and specialist mental health provision, should have a mechanism in place
addressing people’s health needs has to be part of the solution to ensure their mental health services can support rough sleepers.”18
to homelessness. Local plans should include a mental health needs assessment for
rough sleepers which will identify need and increase access to
mental health services, and ensure such services adopt a trauma-
Government action prior to informed approach.
Covid-19
In recent years, in response to rapid increases in rough sleeping,
the Government has recognised that “too many people still sleep
rough on our streets” and that “the human cost of this, in broken
lives too often cut short, is unacceptable,”15 and has taken action
to help reduce rough sleeping and improve health outcomes for
those experiencing homelessness.
In 2019, 778 people died while sleeping
Through the Rough Sleeping Initiative and other pilots and rough or in emergency accommodation,
programmes initiated as part of the 2018 Rough Sleeping an increase of 7% from 2018.
Strategy, the Government has invested in providing emergency
support to people who are sleeping rough. This investment
has enabled local authorities, working in partnership with
service providers, to scale up services such as street outreach,
emergency accommodation, assessment and rapid rehousing
services, including No Second Night Out and Somewhere Safe
to Stay, tenancy support and Housing First services.
The strategy also pledged “up to £2 million in health funding to
enable access to health and support services for people who are
sleeping rough” and underlined the fact that that local authorities
were ‘legally obliged” to house “those who are vulnerable as a
result of their health.”16 The Homelessness Reduction Act (2017)
introduced a duty for certain public bodies, including social
services and hospitals, to refer anyone who is homeless or at
risk of homelessness to their local housing authority, setting
“an expectation of closer working between the health and housing
sectors.”17
15 MHCLG (2018) Rough Sleeping Strategy 2018
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733421/Rough-Sleeping-Strategy_WEB.pdf
16 Ibid.
17 The King’s Fund (20220) Delivering health and care for people who sleep rough: going above and beyond
https://www.kingsfund.org.uk/publications/delivering-health-care-people-sleep-rough
18 NHS (2019) NHS Mental Health Implementation Plan 2019/20 – 2023/24
https://www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf
13Section 3
In 2019 the Government made a renewed commitment in The action was critical, not only because those sleeping rough
their General Election manifesto to end rough sleeping by are particularly vulnerable to severe cases of Covid-19, but also
2024 by “working to bring together local services to meet the because they are some of those least able to follow public
health and housing needs of people sleeping on the streets.”19 The health advice. Advice to stay at home is meaningless to those
2020 Spring Budget announced funding of £262 million for without one.
specialist substance use treatment services for people sleeping
rough, although this has yet to be spent. The 2020 Spending St Mungo’s has been heavily involved in this effort, supporting
Review went further, confirming funding from the Shared clients to find emergency accommodation, follow public health
Outcomes Fund to provide improved support to individuals guidance, and access services including mental health support
experiencing multiple and complex needs, such as homelessness and drug and alcohol services. As of the beginning of December
and substance use (£46m) and step-down accommodation 2020, St Mungo’s had managed 30 emergency hotels, of which
and support from hospital for individuals who are homeless 11 were still open. In total, since the start of the pandemic, we
(£16m).20 This has now been allocated through the Changing had supported 3,364 people staying in emergency Covid-19
Futures Fund (£23 million 2020/2021 with a further £52 million accommodation. 32% of clients supported in emergency
in 2021 to 2022), announced on 11 December 2020, in which accommodation were BAME, 16% were women.
43 areas across England will receive support to help improve For those who did come inside, the hotels have also provided
the way that systems and services work to support individuals a foundation for further recovery. As of the beginning of
experiencing multiple disadvantage.21 December, St Mungo’s had helped 1,300 people move on from
These are significant, positive steps towards a truly cross- emergency accommodation to longer term housing, including
government approach to ending rough sleeping. However, much homes in the social, supported and private rented sectors.
of this work has also been disrupted or delayed by Covid-19. One of St Mungo’s clients, Ian, moved from an emergency
hotel into a flat through the Clearing House programme, which
Everyone In: responding to the provides social housing and tenancy sustainment support for
people who have slept rough in London. “They gave me a home,
threat of Covid-19 for people they got my Universal Credit going, I’ve got a studio flat now - I have
sleeping rough the keys…I have a house, in a nice neighbourhood, by the Thames.”
There is no doubt that the progress described above helped
lay the foundations for a swift and decisive response to rough The crisis continues
sleeping when the first wave of Covid-19 arrived in the UK. In During the first wave of Covid-19, the number of people seen
particular, the newly expanded rough sleeping and homeless sleeping rough plummeted thanks to the Everyone In initiative.
health services were well placed to respond. According to the Government, more than 90% of rough
At the start of the first national lockdown in March 2020, acting sleepers known to councils at the beginning of the pandemic
on a very legitimate concern for the health of people sleeping were offered safe, emergency accommodation, in the space of
rough, the Government launched the Everyone In initiative. two months.22
Government Ministers tasked local authorities in England with
supporting everyone sleeping rough, or in accommodation
where it was difficult to self-isolate (such as communal shelters),
to move into emergency accommodation including hotels, 32% of clients supported
hostels and B&Bs. According to the Government, this initiative in emergency accommodation
has led to more than 33,000 people being moved into safe were BAME, 16% were women
emergency accommodation.
19 Conservative Party (2019) The Conservative and Unionist Party Manifesto 2019
https://assets-global.website-files.com/5da42e2cae7ebd3f8bde353c/5dda924905da587992a064ba_Conservative%202019%20Manifesto.pdf
20 HM Treasury (2020) Spending Review 2020
https://www.gov.uk/government/publications/spending-review-2020-documents/spending-review-2020#shared-outcomes-fund
21 MHCLG (2020) Extra help for rough sleepers with drug and alcohol dependency
https://www.gov.uk/government/news/extra-help-for-rough-sleepers-with-drug-and-alcohol-dependency
14Policy context
However, thousands of people have still slept rough during the In previous years, communal shelters have been widely used to
pandemic. Interviews conducted for this report revealed that provide emergency accommodation to people sleeping rough,
hotels filled up prior to finding a room for everyone. As one particularly during the winter months. However, communal
homeless health nurse reported: “Their names had been put on shelters are also known to put people at high risk of contracting
waiting list to go into hotels but they filled up quickly and funding ran Covid-19. In a study by the Coalition for the Homeless it was
out.” found that the mortality rate from Covid-19 for people staying
in homeless shelters in New York City was 61% higher than
Crucially, the number of people sleeping rough is not static and the rate among the general population.28 In October 2020, the
there has continued to be a flow of people onto the streets Government published guidance on the use of winter shelters
during the pandemic. The CHAIN report on rough sleeping in for people sleeping rough, but stopped short of ruling out the
London covering the period from April to June 2020 showed use of communal shelters altogether, saying instead they should
an initial surge in rough sleeping during the first lockdown, with only be used as a last resort.
a 77% increase in the number of people found sleeping rough
for the first time in the capital, and a 33% increase in the total To support this approach, the Government has provided specific
number sleeping rough compared to the same period in 2019 funding to help local authorities continue to provide self-
(up from 3,172 in Q1 2019/20 to 4,227 in Q1 2020/21).23 contained emergency accommodation for people sleeping rough,
as well as longer-term housing and support, through the Next
Since then, the number has decreased with CHAIN data for July Steps Accommodation Programme, the Cold Weather Fund and
to September 2020 showing 3,444 people were seen sleeping the Protect Programme. The latter of which was announced at
rough during the summer, which is 14% lower compared to the start of the second national lockdown in November 2020.
the same period in 2019. However, 55% of those seen were However, several local and combined authorities have said that
new to the street.24 Elsewhere in the country, local authorities the funding is not enough to ensure that everyone who needs it
and outreach services have reported a rise in the number seen can access safe, individual accommodation.29
sleeping rough following the initial drive to get ‘everyone in’.25
National StreetLink data for January-September 2020 shows an In January 2021, the Government announced a further £10
82% increase in requests for help from individuals rough sleeping million to help local authorities provide accommodation for
(self-alerts) compared to 2019 (from 5,503 to 10,006).26 people sleeping rough, and to assist with GP registration to help
with access to the Covid-19 vaccine.
While the Government has stated that Everyone In continues,
Ministers haven’t re-issued the same clear expectations, guiding Saving the lives of some of the most vulnerable in our society
principles and the levels of funding needed, which were core has been at the core of the Government’s response to rough
ingredients of the approach to providing safe, emergency sleeping during Covid-19. The risks of sleeping rough during
accommodation for everyone, including those with no recourse the coronavirus pandemic are further exacerbated by cold
to public funds, during the first wave.27 weather. It is vital that everyone who is on the streets, or
who is at risk of rough sleeping, can continue to access
self-contained accommodation immediately, with adequate
support where it is needed.
22 MHCLG (2020) 6,000 new supported homes as part of landmark commitment to end rough sleeping
https://www.gov.uk/government/news/6-000-new-supported-homes-as-part-of-landmark-commitment-to-end-rough-sleeping
23 GLA (2020) CHAIN Quarterly Report Greater London April - June https://data.london.gov.uk/dataset/chain-reports
24 GLA (2020) CHAIN Quarterly Report Greater London July - September 2020 https://data.london.gov.uk/dataset/chain-reports
25 BBC (November 2020) Bristol homeless: ‘Toughest winter yet’ for rough sleepers https://www.bbc.co.uk/news/uk-england-bristol-54936668
26 Homeless Link (November 2020) Bring Everyone In again: lessons and leadership for lockdown two to prevent a homelessness crisis
https://www.homeless.org.uk/sites/default/files/Briefing%20Everyone%20In%202_final_clean.pdf
27 MHCLG (March 2020) Letter from Minister Hall to local authorities
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/928780/Letter_from_Minister_Hall_to_Local_Authorities.pdf
28 Coalition for the homeless (2020) Covid-19 and homelessness in New York City
https://www.coalitionforthehomeless.org/wp-content/uploads/2020/06/COVID19HomelessnessReportJune2020.pdf
29 Griffiths N. (October 2020) Government’s new £12m winter fund for rough sleeping ‘not enough’, say Manchester council and charities
https://www.manchestereveningnews.co.uk/news/greater-manchester-news/governments-new-12m-winter-fund-19101806
154 The health needs of homeless people 16
People who are sleeping rough face some of the worst health People who have slept rough have high levels of respiratory
inequalities in society illness and frailty, and die far younger than the general
People sleeping rough are at much greater risk of mental and population
physical health problems than the general population and their Crucially for the current Covid-19 crisis, people who have
experiences of sleeping on the streets often make it more slept rough report extremely high levels of respiratory illness
difficult to access the healthcare they need. when compared to the general population. One study found
that 64% of participants who had slept rough reported having
Evidence strongly suggests that people who sleep rough often had chest infections, 30% of participants had been admitted to
experience even worse health outcomes than the wider group hospital for ‘frightening breathlessness’, and 20% of participants
of people who are homeless.30 For instance, in one recent reported that they had asthma compared to 8.4% in the general
study in the United Kingdom, drug and alcohol problems were population.33
significantly higher among people sleeping rough than the wider
definition of ‘single homeless’ people.31 Further, research by a group of Pathway Fellows found that in
a complex needs hostel in south London for people who had
Furthermore, the longer that people sleep rough, the worse been sleeping rough, the average age of hostel residents was 56
their health needs become as these needs are compounded by but the level of frailty was equivalent to an 89 year old in the
the traumatic experience of sleeping rough. Research published general population. They also established an average of more
by St Mungo’s earlier this year revealed that people who sleep than seven long term conditions per person, which is far greater
rough for longer are more likely to have drug and alcohol than the average for even the oldest people in the general
problems.32 population.34
Although this report focuses specifically on people who have On 14 December 2020, the ONS released data which showed
experienced, or who are, rough sleeping, some of the studies a record number of people dying while sleeping rough or in
referred to do not distinguish people who sleep rough from the emergency accommodation. 778 people died in 2019, a 7.2%
wider homeless population. However, they still give an overview rise on the previous year.35 That is more than 16 people dying
of just how extensive and severe the health needs amongst every week.
those rough sleeping are, and the health inequalities they
experience when compared to the wider population. Further, these deaths were overwhelmingly premature and
largely preventable. The ONS data showed that the average
age of death for those sleeping rough or in emergency
accommodation was only 45.9 for men. For women it was
43.4.36 A study in 2019 showed that after adjusting for age
and sex, nearly one in three of the deaths among people who
were homeless were due to conditions such as tuberculosis
and gastric ulcers which are amenable to timely and effective
health care.37
30 Elwell-Sutton T., Fok J., Albanese F., Mathie H., Holland R., (2017) Factors associated with access to care and healthcare utilization in the homeless
population of England https://academic.oup.com/jpubhealth/article/39/1/26/3065715
31 Ibid.
32 St Mungo’s (2020) Knocked Back: Failing to support people sleeping rough with drug and alcohol problems is costing lives
https://www.mungos.org/app/uploads/2020/01/StM_Knocked_Back_DA_Research_Report_Final_2901.pdf
33 Groundswell (2016) Room to Breathe https://groundswell.org.uk/wp-content/uploads/2018/10/Groundswell-Room-to-Breathe-Full-Report-2016.pdf
34 Rogans-Watson R., Shulman C., Lewer D., Armstrong M., Hudson B. (2020) Premature frailty, geriatric conditions and multimorbidity among people experiencing
homelessness: a cross-sectional observational study in a London hostel
https://www.emerald.com/insight/content/doi/10.1108/HCS-05-2020-0007/full/html?mc_cid=58daf4f026&mc_eid=f60669dcec
35 ONS (2020) Deaths of homeless people in England and Wales: 2019 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/
bulletins/deathsofhomelesspeopleinenglandandwales/2019registrations
36 ONS (2020) Deaths of homeless people in England and Wales: 2019 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/
bulletins/deathsofhomelesspeopleinenglandandwales/2019registrations
37 Aldridge RW., Menezes D,, Lewer D. et al. (2019) Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality
data in England https://wellcomeopenresearch.org/articles/4-49/v1
17Section 4
There are significant barriers to accessing timely health care A persisting problem with GP registration is that people are
and this exacerbates health inequalities refused on the grounds of lacking ID, having no fixed address or
not being able to prove their immigration status. This is despite
Many people who are homeless — both those sleeping rough, NHS guidelines stating: “You should not be refused registration
and those who fall under a wider definition of homelessness or appointments because you do not have a proof of address or
— experience significant barriers in accessing the timely health personal identification at hand. It’s not considered a reasonable
care they need. Groundswell’s ‘More than a Statistic’ research ground to refuse registration.”42
revealed that one of the key barriers that people who are
homeless face to getting healthcare is registering and making use Research for this report also revealed problems associated with
of a GP practice.38 people sleeping rough being registered with a GP in a different
area to the one they were staying in, which also made it harder
This is very important as a GP is a gateway to access other to get the help they needed.
health services, as well as a preventative measure to avert
increased A&E visits. Difficulties in seeing a GP also mean that People sleeping rough also find it difficult to access other health
homeless people are often not participants in NHS vaccination services, including mental health and substance use services. Such
and screening programmes, such as influenza vaccinations. difficulties are likely the result of a combination of factors, which
Amongst the homeless population, “vaccine uptake levels are less include inadequate signposting; a lack of knowledge of services;
than half those seen among eligible GP patient groups in England”.39 fear of stigmatisation; attitudinal issues within services; and
This is also most likely an underestimate due to the prevalence financial barriers such as paying for travel to appointments.43 44
of undiagnosed health conditions.40 Without a concerted effort,
the same issues are likely to arise with the Covid-19 vaccine. There are also barriers which are a result of the nature of
sleeping rough and the daily challenges this causes. Due to the
Access to GPs is especially low amongst people who sleep reduction in drug and alcohol outreach services in recent years,
rough. A study in 2016 showed that 66.5% of those rough and fewer specialist workers able to engage people where they
sleeping were registered with a GP compared with single are, people are often required to attend drop-ins followed
homeless people in accommodation and people who are hidden by structured appointments in order to access substance use
homeless (83.1% and 88.4%, respectively).41 services. This problem was highlighted by St Mungo’s ‘Knocked
Back’ research into drug and alcohol problems and rough
sleeping, published in February 2020, in which one interviewee
noted that “My God, and I don’t have an alarm clock, I don’t have a
diary, I don’t have a phone, I don’t have any way to even know what
day it is some days.”45
38 Groundswell (2016) More than a Statistic https://groundswell.org.uk/wp-content/uploads/2018/10/NHS100012_More-than-a-statistic-Final-2017-1.pdf
39 NICE (2018) Flu vaccination: increasing uptake https://www.nice.org.uk/guidance/ng103/evidence/expert-paper-3-homeless-outreach-pdf-6532123791
40 Ibid.
41 Elwell-Sutton T., Fok J., Albanese F., Mathie H., Holland R., (2017) Factors associated with access to care and healthcare utilization in
the homeless population of England https://academic.oup.com/jpubhealth/article/39/1/26/3065715
42 NHS (2019) How to register with a GP practice https://www.nhs.uk/using-the-nhs/nhs-services/gps/how-to-register-with-a-gp-practice/
43 Burwood, S., Chandan, S., Gunner, E., Marwick, S., Paudyal, V., Saunders, K., and Yahyouche, A., (2019) Provision and accessibility of primary healthcare
services for people who are homeless: a qualitative study of patient perspectives in the UK https://bjgp.org/content/69/685/e526
44 Groundswell (2016) More than a Statistic https://groundswell.org.uk/wp-content/uploads/2018/10/NHS100012_More-than-a-statistic-Final-2017-1.pdf
45 St Mungo’s (2020) Knocked Back: Failing to support people sleeping rough with drug and alcohol problems is costing lives
https://www.mungos.org/app/uploads/2020/01/StM_Knocked_Back_DA_Research_Report_Final_2901.pdf
18The health needs of homeless people
Difficulty in accessing health services can lead to people’s health Non-UK nationals face specific
problems becoming more acute, or to them trying to access
healthcare in other ways. A study in Birmingham, which looked challenges
at patient data from a specialist primary healthcare service, It is important to note that non-UK nationals who are homeless
found that homeless people were 60 times more likely to visit face considerable difficulty accessing health services. Some health
A&E than the general population.46 This problem is increasing. services such as community mental health services and some
A study by the British Medical Association (BMA) found that aspects of drug and alcohol treatment are not free for certain
the number of recorded visits to emergency departments non-UK nationals and must be paid for up front, restricting
by patients classed as having no fixed address almost trebled the number of people who can access them. There are further
between 2010-11 and 2017-18.47 problems for this group in terms of language barriers and a
lack of understanding among all concerned about the effect of
This is extremely concerning given that A&E services are less an individual’s immigration status on their eligibility for certain
able to provide holistic support for individual’s with multiple and services.
complex needs, whilst costing far more than primary care.48
And yet we know non-UK nationals make up a significant
In response to the difficulty in accessing health services and proportion of people sleeping rough in England. According to
in order to tackle health inequalities among people who are government statistics, 26% of people sleeping rough in England
homeless, some specialist GP practices and homeless health on a single night in autumn 2019 were non-UK nationals. A
services have been established. These are set up to ensure that recent report by LSE found that more than a quarter of those
health services are available for marginalised groups, such as accommodated in London between April-June under Everyone
people who are homeless, sex workers and Gypsies, Roma and In had ‘no recourse to public funds’ conditions as a result of their
Travellers. One such example is Great Chapel Street, which is immigration status.49
a walk-in medical centre for homeless people in Westminster.
Some services have been established for a long-time, others have Although published and academic literature suggests that
been set-up more recently in response to rising rough sleeping. migrants sleeping rough tend to have less complex needs this
However, there is still not sufficient, or consistent provision of difference is becoming less pronounced: in 2014-2015, 41% of
these specialist services across the country. non-UK nationals sleeping rough in London had drug and alcohol
problems compared to 52% in 2018-2019. Further, sleeping
Changes in access to health services during the Covid-19 rough takes a significant toll on a person’s physical and mental
pandemic will be explored in Section 7. health. Difficulties in accessing health services compound this and
can lead to a downward spiral of ill health.
46 Bowen M., Marwick S., Marshall T., Saunders K., Burwood S., Yahyouche A., et al. (2019) Multimorbidity and emergency department visits by a homeless population: a
database study in specialist general practice https://bjgp.org/content/69/685/e515#xref-ref-6-1
47 BMJ (2019) Homeless people’s A&E visits treble in seven years https://www.bmj.com/content/364/bmj.l323
48 Centre for Policy Studies (2014) How much do we use the NHS? https://www.cps.org.uk/files/reports/original/141028143252-HowMuchDoWeUsetheNHS.pdf
49 Scanlon K., Whitehead C. (2020) London local government expenditure on ‘Everyone In’
https://blogsmedia.lse.ac.uk/blogs.dir/119/files/2020/11/Costs-of-Everyone-In-LSE-London.pdf
195 Assessing the health needs of homeless people during Covid-19 20
Covid-19 has meant an increased focus on the health needs of
people sleeping rough. As a result of this, updated evidence has
emerged. This section looks at data from two health assessment
tools used to help support people during Covid-19: St Mungo’s
own Covid-19 Assessment; and the COVID-19 Homeless Rapid
Integrated Screening Protocol (CHRISP) assessment. These
assessments are used to better understand the needs of clients
and whether they are being met. They also enable service
providers to follow the Public Health England approach to
triaging, assessing and accommodating clients in defined cohorts
during this period based on their vulnerability to Covid-19 or
whether they have symptoms of the virus.
CHRISP assessment data
The CHRISP assessment was carried out for people in
emergency hotels in London, those accommodated under
Everyone In as they had previously been sleeping rough or in
accommodation where it was difficult to self-isolate (such as
night shelters). There were generally three types of hotel for
differing needs:
▪ Covid-Care hotels for people who were symptomatic or had
tested positive;
▪ Covid-Protect sites for those who were asymptomatic but at
increased risk from Covid-19
▪ Covid-Prevent sites for asymptomatic individuals with no
increased vulnerability.
The CHRISP assessment covered all three types of hotel. It was
carried out by medically trained professionals, the majority of
whom were doctors.
The CHRISP assessment found that 37% of clients had mental
health problems, 19% (223 people) had self-identified drug
problems, and 166 people self-declared problematic alcohol
use.50 15% had dual diagnosis of mental health and drug and
alcohol problems; close to 40% of those assessed had chronic
dental pain; and around 40% had memory cognition problems.51
50 Pan-London Homeless Hotel Drug & Alcohol Support Service (HDAS)
(2020) Lessons Learned http://osf.io/7cdbx/
51 Healthy London Partnerships (2020) Homeless health - next steps for London:
health needs assessments & the importance of MDTs
https://www.youtube.com/watch?v=SLOGIIhDXus&feature=youtu.be
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